Transtheoretical 5 Stages of Change Model

The change process has been conceptualized as a sequence of stages through which people typically progress as they think about, initiate, and maintain new behaviors (Prochaska and DiClemente, 1984).

1. Precontemplation

During the precontemplation stage, substance-using persons are not considering change and do not intend to change behaviors in the foreseeable future. They may be partly or completely unaware that a problem exists, that they have to make changes, and that they may need help in this endeavor. Alternatively, they may be unwilling or too discouraged to change their behavior. Individuals in this stage usually have not experienced adverse consequences or crises because of their substance use and often are not convinced that their pattern of use is problematic or even risky.

2. Contemplation

As these individuals become aware that a problem exists, they begin to perceive that there may be cause for concern and reasons to change. Typically, they are ambivalent, simultaneously seeing reasons to change and reasons not to change. Individuals in this stage are still using substances, but they are considering the possibility of stopping or cutting back in the near future. At this point, they may seek relevant information, reevaluate their substance use behavior, or seek help to support the possibility of changing behavior. They typically weigh the positive and negative aspects of making a change. It is not uncommon for individuals to remain in this stage for extended periods, often for years, vacillating between wanting and not wanting to change.

3. Preparation

When an individual perceives that the envisioned advantages of change and adverse consequences of substance use outweigh any positive features of continuing use at the same level and maintaining the status quo, the decisional balance tips in favor of change. Once instigation to change occurs, an individual enters the preparation stage, during which commitment is strengthened. Preparation entails more specific planning for change, such as making choices about whether treatment is needed and, if so, what kind. Preparation also entails an examination of one’s perceived capabilities—or self-efficacy—for change. Individuals in the preparation stage are still using substances, but typically they intend to stop using very soon. They may have already attempted to reduce or stop use on their own or may be experimenting now with ways to quit or cut back (DiClemente and Prochaska, 1998). They begin to set goals for themselves and make commitments to stop using, even telling close associates or significant others about their plans.

4. Action

Individuals in the action stage choose a strategy for change and begin to pursue it. At this stage, clients are actively modifying their habits and environment. They are making drastic lifestyle changes and may be faced with particularly challenging situations and the physiological effects of withdrawal. Clients may begin to reevaluate their own self-image as they move from excessive or hazardous use to nonuse or safe use. For many, the action stage can last from 3 to 6 months following termination or reduction of substance use. For some, it is a honeymoon period before they face more daunting and longstanding challenges.

5. Maintenance

During the maintenance stage, efforts are made to sustain the gains achieved during the action stage. Maintenance is the stage at which people work to sustain sobriety and prevent recurrence (Marlatt and Gordon, 1985). Extra precautions may be necessary to keep from reverting to problematic behaviors. Individuals learn how to detect and guard against dangerous situations and other triggers that may cause them to use substances again. In most cases, individuals attempting long-term behavior change do return to use at least once and revert to an earlier stage (Prochaska et al., 1992). Recurrence of symptoms can be viewed as part of the learning process. Knowledge about the personal cues or dangerous situations that contribute to recurrence is useful information for future change attempts. Maintenance requires prolonged behavioral change—by remaining abstinent or moderating consumption to acceptable, targeted levels—and continued vigilance for a minimum of 6 months to several years, depending on the target behavior (Prochaska and DiClemente, 1992).

CLIENT’S STAGE OF CHANGE AND THE APPROPRIATE MOTIVATIONAL

(Miller & Rollnick)

#1. Precontemplation: the client is not yet considering change or is unwilling or unable to change.

Establish rapport, ask permission, and build trust.

Raise doubts or concerns in the client about substance-using patterns by Exploring the meaning of events that brought the client to treatment or the results of previous treatments Eliciting the client’s perceptions of the problem.

Offering factual information about the risks of substance use.

Provide personalized feedback about assessment findings.

Exploring the pros and cons of substance use,

Examine discrepancies between the client’s and others’ perceptions of the problem behavior.

Express concern and keep the door open.

#2. Contemplation: The client acknowledges concerns and is considering the possibility of change but is ambivalent and uncertain.

Normalize ambivalence: Help the client “tip the decisional balance scales” toward change by Eliciting and weighing pros and cons of substance use and change.

#4. Action Engage the client in treatment and reinforce the importance The client is actively taking steps to change but has not yet reached a stable state of remaining in recovery.

Support, a realistic view of change through small steps.

Acknowledge difficulties for the client in early stages of change.

Help the client identify high-risk situations through a functional analysis and develop appropriate coping strategies to overcome these.

Assist the clientin finding new reinforcers of positive change.

Help the client assess whether she has strong family and social support.

#5. Maintenance Help the client identify and sample drug-free sources of The client has achieved initial goals such as abstinence and is now working to maintain gains. pleasure (i.e., new reinforcers).

Support lifestyle changes.

Affirm the client’s resolve and self-efficacy.

Help the client practice and use new coping strategies to avoid a return to use.

Maintain supportive contact (e.g., explain to the client that you are available to talk between sessions). Develop a “fire escape” plan if the client resumes substance use.

#6. RecurrenceHelp the client reenter the change cycle and commend any The client has experienced a recurrence of symptoms and must now cope with consequences and decide what to do next willingness to reconsider positive change.

Explore the meaning and reality of the recurrence as a learning opportunity.